Provider Demographics
NPI:1952583841
Name:GEOGHAN, CORI J (DPT)
Entity Type:Individual
Prefix:MS
First Name:CORI
Middle Name:J
Last Name:GEOGHAN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:MS
Other - First Name:CORI
Other - Middle Name:
Other - Last Name:JEWETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:17210 VAN WAGONER RD
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49456-9702
Mailing Address - Country:US
Mailing Address - Phone:616-296-2262
Mailing Address - Fax:616-935-3535
Practice Address - Street 1:17210 VAN WAGONER RD
Practice Address - Street 2:
Practice Address - City:SPRING LAKE
Practice Address - State:MI
Practice Address - Zip Code:49456-9702
Practice Address - Country:US
Practice Address - Phone:616-296-2262
Practice Address - Fax:616-935-3535
Is Sole Proprietor?:No
Enumeration Date:2007-12-03
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501013536225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP14760008Medicare PIN